A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Click to highlight the data that indicate the client is in need of immediate health interventions.

A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale:

The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.

Choice B rationale:

This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.

Choice C rationale:

This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.

Choice D rationale:

While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.

Choice E rationale:

The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

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Correct Answer is D

Explanation

This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
a) Serum calcium
This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be aﬀected by kidney disease, but it is not a reliable indicator of nephrotoxicity.

b) Hemoglobin and hematocrit
This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.

Hemoglobin and hematocrit may be aﬀected by kidney disease, but they are not reliable indicators of
nephrotoxicity.

c) White blood cell count (WBC)
This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inﬂammation, but it is not a reliable indicator of nephrotoxicity.
Kidney

A. Instill 3 mL of normal saline before suctioning. B. Instruct the client to cough as the suction tip is removed. C. Apply a water-soluble lubricant to the catheter. D. Wear protective goggles while performing the procedure. E. Wear protective goggles while performing the procedure.

Correct Answer is D

Explanation

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Correct Answer is D

Explanation

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Correct Answer is D

Explanation

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The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

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